Key features of adolescent inpatient units and development of a checklist to improve consistency in reporting of settings

Accessible summary What is known on the subject? Little is known about adolescent inpatient units, key features which define them, and how these essential services operate and deliver care. What the paper adds to existing knowledge? Adolescent inpatient unit studies are limited in their descriptions of settings in terms of how they operate and key features. The proposed preliminary checklist is a practical tool to assist clinicians, policy makers, and researchers when reporting to ensure comprehensive descriptions of adolescent inpatient settings. What are the implications for practice? This could be used to inform service design processes for inpatient and other mental health service models which is of critical importance in the context of reforms and implementation of these in Australia currently. Greater attention to operational models, services, and philosophies of practice will improve reporting and allow for the advancement of knowledge, comparison of study results, and a clearer direction for mental health nursing clinicians and researchers. Abstract Introduction Adolescent inpatient units care for vulnerable population groups; however, little is known about how these essential services operate and deliver care. Aims To examine the descriptions of adolescent mental health inpatient units in Australian and international research publications and to identify key features which were used to define them. A secondary aim was to develop a checklist to improve consistency when reporting on the operations and services delivered within adolescent mental health inpatient units (both public and private). Methods Five electronic databases (CINAHL, MEDLINE, ERIC, EMBASE, and PsycINFO) were systematically searched. We included studies that provided descriptions of operations and services within adolescent inpatient units where participants had a mean age between 12 and 25. Narrative synthesis was used to explore the similarities and differences between descriptions of settings. Results Twenty‐eight studies were identified, which varied in their descriptions of adolescent inpatient units, providing inconsistent information to inform best practice. Discussion Studies lack consistency and comprehensive detail when describing the operational models within inpatient units, making interpretation challenging. Consequently, a preliminary checklist is proposed to improve reporting of adolescent inpatient units.


| INTRODUC TI ON
Since March 2020, healthcare systems and settings (particularly hospital-based services) have faced additional challenges with the outbreak of the novel coronavirus   (Delaney, 2021). The COVID-19 global pandemic had caused nurses to be challenged beyond their own limits, adjusting to a "new normal" (Delaney, 2021;Maben & Bridges, 2020, p. 2742. Evidence from the United Kingdom (UK) and United States (US) report that psychological distress symptoms have increased in the community during the pandemic, with those aged 13 to 26 years exhibiting the greatest deterioration (McGinty et al., 2020;O'Reilly et al., 2020;Pierce et al., 2020; Wisconsin Office of Children's Health, 2021). Mental health services transitioned in a matter of days from face-to-face care to telehealth and virtual modes of delivery (Maben & Bridges, 2020). The effects of COVID-19 are likely to have long-lasting impacts for physical and mental healthcare systems (McBride et al., 2021).
The need for transparency in reporting of healthcare settings pre-dated the pandemic and is more important than ever in assisting healthcare systems navigate through the coming years and additional challenges related to the lasting consequences of COVID-19.
Although community care is prioritized over inpatient treatment for adolescents, the acuity and severity of clinical symptoms may necessitate this level of care (Carlson & Elvins, 2021). Adolescent inpatient units are beneficial when they provide specialist care that other components of the system of care cannot (Hazell, 2021). Inpatient admissions are often required when all other treatment options have been attempted (Carlson & Elvins, 2021) or there is no alternative available to meet the severity of a person's needs.
Admissions typically occur for the purpose of (a) detailed observation to facilitate diagnosis, (b) to initiate supervised treatment, and/ or (c) acute containment of risk (Hazell, 2021;Perkes et al., 2019).
While there has been a proliferation of recent articles focusing on specific therapies such as Dialectical Behaviour Therapy (DBT) or Cognitive Behaviour Therapy (CBT) that may be used in these settings, research that describes operations and models of care within child and adolescent inpatient units remains limited (Delaney, 2019;Hayes et al., 2020aHayes et al., , 2020bSaito et al., 2020).
Existing research tends to address characteristics influencing admissions, such as length of stay or therapeutic outcomes following an admission (Benarous et al., 2021). Less is known about adolescent inpatient units, such as their key features and how and why these specialist programs address major mental health issues (in terms of how they operate and function) (Delaney, 2019;Hayes et al., 2018;Mojtabai et al., 2016). Key features can include the mean age of adolescents admitted, voluntary or involuntary units, and group therapy sizes for example. Furthermore, less is known about the inpatient unit philosophies of practice, services, and therapeutic offerings such as types of group therapies and discharge support services including links to community supports. There are some communities where general adolescent inpatient units are unavailable or inaccessible. Consequently, adolescents are often admitted to adult services or receive no service (McRae et al., 2021).
Globally, countries will vary in terms of adolescent age ranges, with many overlapping ranges from birth to adulthood (Clark et al., 2015). In Australia, "there are no universally accepted paediatric definitions within health" (Clark et al., 2015(Clark et al., , p.1011. However, from a mental health perspective, adolescent services in Australia typically admit those from ages 12 to 25 (Garner et al., 2008;Hayes et al., 2018Hayes et al., , 2020bHense et al., 2018). To our knowledge, there are little or no inpatient mental health services for those below 12 years of age in Australia. In America, adolescent (also termed paediatric/child) mental health services can admit those from ages 5-18 (Johnson et al., 2020;Kennard et al., 2018;Makki et al., 2018;Sams et al., 2016Sams et al., , 2018Vidal et al., 2020;Wolff et al., 2018). Adult mental health services in Australia would typically be from age 18 onwards (Hu et al., 2019).
In a systematic review, Hayes et al. (2018) examined 16 studies of 30 national and international child and adolescent inpatient units to evaluate the effectiveness of care and found that the majority had a mean age between 12 and 25. Narrative synthesis was used to explore the similarities and differences between descriptions of settings.

Results:
Twenty-eight studies were identified, which varied in their descriptions of adolescent inpatient units, providing inconsistent information to inform best practice.
Discussion: Studies lack consistency and comprehensive detail when describing the operational models within inpatient units, making interpretation challenging.
Consequently, a preliminary checklist is proposed to improve reporting of adolescent inpatient units.

K E Y W O R D S
Adolescent, Child, Inpatient Units, Mental Health, Model of Care of adolescents improved in at least one area of symptomatology by discharge. The authors emphasized the need for further detail regarding adolescent inpatient unit operations and models of care (e.g., types of groups offered and description of experiences of adolescents participating in care). Features, which were listed included some demographic information such as age, gender, or the average length of stay of adolescents who were admitted. There was little to no information on therapeutic models of care, groups offered, and outcomes according to different therapeutic models nor the experiences of adolescents who engaged in those models. With limited evidence of effectiveness available, it is unlikely that high quality, safe, and effective inpatient programs simply occur or that any professional group could create a therapeutic milieu as well as any other (Delaney, 2017(Delaney, , 2019. Adolescent inpatient literature tends to focus on symptomatology outcomes or rather than clinically and indeed in some instances non-clinically, meaningful outcomes which are central to patient's experience of care (Steele, 2021). Therefore, while clinicians and researchers are informed of the clinical outcomes, details from how care starts, what is delivered within the care journey, and up to and including endpoints remain ambiguous; in turn, this limit how data are utilized. According to Fung et al. (2008), reporting of data is proposed as a mechanism for improving quality of care and safety by providing more transparency for clients and clinicians. Comprehensive and clear reporting is paramount for the translation of research findings into improved service delivery (Borek et al., 2015;Davidson et al., 2003).
To our knowledge, no comprehensive checklist has been developed to guide the descriptions and reporting of general adolescent mental health inpatient units. Research has supported the utility for such clinical practice checklists (Brouwers et al., 2016;Harris & Russ, 2021;Tokalić et al., 2020). For clinical practice guidelines, the international Appraisal of Guidelines, Research and Evaluation (AGREE) research team developed a checklist (Makarski & Brouwers, 2014). This has been widely used for evaluating methodological quality and transparency of practice guidelines internationally (Brouwers et al., 2016;Makarski & Brouwers, 2014).
Clinical practice guidelines are systematically developed to assist clinician and patient decisions regarding appropriate health care for specific clinical circumstances (Brouwers et al., 2010).
Furthermore, checklists can be, "used to translate evidence into practice by synthesizing strong evidence into actionable recommendations" (Francke et al., 2008;Sanders et al., 2014;Tokalić et al., 2020Tokalić et al., , p. 2167. Shelmerdine et al. (2021) acknowledged that while reporting guidelines have been widely used, additional factors need to be evaluated which might not conform to traditional reporting guidelines.
With changing health interventions, reporting guidelines can help ensure that investigators as well as those appraising studies can consider important features of good design and reporting (Shelmerdine et al., 2021). As we redesign health care systems in the context of the global pandemic and major mental health reforms across numerous nations, such a checklist may also be of benefit. Therefore, this paper presents a systematic review of the reported features of adolescent inpatient units to identify how these are defined and propose a preliminary checklist for reporting.

| AIM
This review aimed to examine the operational and therapeutic model of care descriptions of general adolescent mental health inpatient units in the published literature and identify the key features which define them. The operational model relates to how and what is delivered as part of an inpatient unit. The model of care includes defining elements of the inpatient setting, which make up the model of care, including organizational structure, admission processes, and provision and delivery of all interventions. A secondary aim was to develop a preliminary checklist to utilize when researchers or clinicians report on an adolescent mental health inpatient unit.

| ME THODS/DE S IG N
This review utilized the Population, Intervention, Comparison, and Outcome (PICO) framework to prepare the research question (Abbade et al., 2017). Electronic searches of CINAHL (Cumulative

| Inclusion and exclusion criteria
The studies were included if the inpatient unit had a general focus, rather than for specialty areas such as substance abuse or eating disorder units. Adult and/or paediatric units were excluded. Studies were also included when the mean age of adolescent participants was between 12 and 25, studies were written in English and published between January 2000 and June 2021. The age range of 12-25 was selected as research has expanded the timeframe of adolescence to include young adulthood often up to 25 years of age (Jaworska & MacQueen, 2015). The previous 21 years were deemed sufficient based on the limited studies on adolescent inpatient units, and we also sought to include more contemporary inpatient units.
Primary research of any design was included. Studies were excluded if the setting was based solely on community, outpatient, and/or forensic settings. Furthermore, studies which did not describe the inpatient unit or any therapeutic interventions, were excluded. The search was conducted twice, in April 2018 to resource an early version of this work and in June 2021 to review updated data with same search terms (May 2018-June 2021). On reviewer advice, one further paper was identified, which suggests this was associated with indexing. Full text screening showed that it contained no further fields for use in this analysis.
The following search terms were used for all five electronic databases: ([adolescen* OR "young person*" OR "youth*" OR "young adult*" OR teen* or child*] AND [inpatient* OR "in-patient*" OR client* OR patient* OR "service user*"] AND ["mental health setting*" OR "inpatient unit*" OR in-patient unit*" OR hospital* OR admission* OR "mental health service*" OR "mental health*" OR "general" OR "general inpatient unit*"] AND ["Intervention*" OR "Therap*" OR "Treat*"]). Results were limited to peer-reviewed journals where most reporting of this nature has occurred. The reference lists of included studies were hand-searched to include all relevant empirical studies. When required, we contacted study authors to confirm eligibility and/or to acquire additional data.
We performed the initial search with identified terms and managed references with Endnote X9 software. (EndNote, 2019). We removed duplicate entries and sorted remaining articles. Article titles and abstracts were then double-screened based on the inclusion and exclusion criteria, followed by full texts of selected articles. A randomly selected 20% subsample of full-texts (n = 6) was doublescreened by (de-identified for review). Following this screening process, one article was excluded. This process prompted further scrutiny of multiple site studies against the inclusion and exclusion criteria. No further studies were excluded.

| Data extraction and quality assessment
Researcher (de-identified for review) extracted data from full-text papers using structured tables. These tables included details relating to characteristics of the study and inpatient unit, such as aim, research design, sample size, and sample characteristics (age, gender, ethnicity). The extracted data from all papers were assessed and screened for accuracy and any omitted information. Studies which did not describe characteristics of their inpatient units were excluded. To assess the quality of included studies, the relevant Critical Appraisals Skills Programme (CASP) tool was used (Critical Appraisal Skills Programme, 2018). The CASP tool considers the following issues when appraising a systematic review: are the results valid and what are the results are and will the results help locally.

| Data analysis
A narrative review and synthesis approach was used to analyse the data (Popay et al., 2006). This method comprised four stages. These stages included developing a framework whereby criteria such as the aims and the type of intervention were identified, developing a preliminary synthesis of findings, exploring data relationships, and assessing the robustness of the synthesis (Popay et al., 2006). Narrative synthesis was chosen to "go beyond simple summation, map relationships in the extracted data both within and between studies…drawing upon different types of evidence" (Madden et al., 2018, p. 649). Furthermore, narrative synthesis methods can "bridge the divides between research, practice and policy" (Madden et al., 2018, p. 646). In the current review, this data analysis process was considered appropriate for the application of the findings to assist with bridging the adolescent inpatient gap between theory and practice.

| Study selection
The study selection process has been summarized in Figure 1 Table 1. Most of the studies were from the United States (n = 9) and Australia (n = 8), followed by New Zealand (NZ) (n = 4). Two studies did not provide their location.
Fourteen studies were quantitative, eight retrospective chart reviews, five qualitative, and two mixed-methods. Sample sizes varied greatly across studies, from two participants up to 1733.

| Quality of evidence
The CASP tool was used to assess the quality of the included studies (Critical Appraisal Skills Programme, 2018) (see Table 2). As this review included various study designs, the relevant CASP tool was applied. Ratings of "yes", "no", or "unknown" were used to indicate whether CASP items were demonstrated. The first author independently conducted the quality appraisal of included studies.

| Adolescent samples
Twenty-three studies reported on mean age. See Table 3 for study setting age ranges. For the n = 2 studies that included pre and post samples, the mean age was 13.2 and 13.5 years, respectively. For the n = 21 studies that did not, the mean age was 15.39 years. Remaining studies (n = 6) did not report mean ages. In terms of gender, 25/28 studies reported this. Of these studies (n = 25), 19/24 claimed that cisfemale accounted for more than 50% of the samples. In terms of ethnicity, nine/28 reported on this. For these studies (n = 9), samples were predominantly (>50%) (n = 7) Caucasian, and the remaining two were reported as Black (59.2%) and NZ European (56%). Details reported on the primary diagnosis, comorbidities, and psychotropic medications are presented in Table 1.

| Adolescent inpatient settings
Details of the inpatient unit settings are provided in Table 3. Twentyfive studies presented single inpatient units (public and private), while the remaining four studies included multiple units. Twenty-two studies reported capacity ranging from six to 36 inpatient beds. Five studies reported their annual admission rates which ranged from 230 to 700 people. Twenty-three studies indicated the age range for their inpatient unit settings, which were between the ages of four and 25. For studies which identified the types of adolescents admitted (n = 21), terms commonly used were, 'range of diagnoses,' 'severe psychiatric disorder,' 'crisis presentations,' 'voluntary inpatient treatment,' 'suicidal ideation,' 'acuity of clinical symptoms' and 'acute treatment'. Sixteen studies did not present details of staff working on the inpatient unit setting/s, and none reported on whether this included peer workforce members (for example, consumer and/or carer consultants or peer support workers). 'Multidisciplinary Team' was the most commonly used term, while 'Teachers' were included for those inpatient units with attached schools. One study identified the number of nurses per shift.
The average length of stay (LOS) was reported in 14 studies, with a mean LOS of 30 days. The LOS range was reported in six studies and ranged from one to 609 days. The client to clinician ratio was reported in three studies (1:3, 1:4, and 1:5). Some studies (n = 6) reported services such as outpatient services (n = 4) and schools (n = 2). Studies also reported on location of inpatient unit, referral sources, catchment areas, secure or non-secure unit, unit aims, objectives, and philosophy. Of the 29 studies included in this review, some studies have described the same inpatient unit setting (Bobier et al., 2009;Hayes et al., 2020aHayes et al., , 2020bSams et al., 2016Sams et al., , 2018Swadi et al., 2010;Swadi & Bobier, 2012). Of these, the same sample was used in two studies (Hayes et al., 2020a(Hayes et al., , 2020b.

| Developing a checklist for reporting
The studies adopted a broad range of key features when describing inpatient units, which are portrayed in Table 5 Garner et al. (2008), Australia

Reynolds et al. (2016) Unknown
unit is publicly or privately funded. For example, a public inpatient unit might be generally crisis-driven, with consequent pressures related to crisis response and discharge to community services as soon  (Rasmussen et al., 2012). Despite the absence of any definition, CAMH nurses play a pivotal role in the inpatient

TA B L E 3 Adolescent inpatient settings
Author (

TA B L E 3 (Continued)
experience and the therapeutic relationships they form with young people. Nurses are available 24/7 to support adolescents when experiencing any distress (Hayes et al., 2020a). Evaluation literature is relatively rich on discussions of best practices in methods (Sridharan & Nakaima, 2011 we sought to assist the descriptions of adolescent inpatient unit studies. The insufficient information regarding each inpatient unit translated to a useful preliminary checklist. We suggest that the proposed checklist could be utilized when describing and reporting general adolescent inpatient units. Furthermore, the checklist can be utilized by key mental health stakeholders to prepare for the re-design and improvements or the evaluation of an inpatient unit. The preliminary checklist is brief which is also a strength.
It provides a framework for evaluation and can be adapted to context-specific factors and therefore be broadly applicable. The checklist can also be employed by researchers and clinicians, so its application is flexible and, as a synthesis of available information, it is more detailed than existing resources.
The evidence available in Tables 1 and 3 demonstrate ambigu-ous adolescent inpatient services, which is potentially frustrating for readers. The resultant inability to utilize information contained in the articles is limited, which would not be the author's intentions. From a clinician and researcher perspective, when reading these articles, there is an attempt to understand the unit from the experience of the adolescent. There is an interest in not only the positive features but the negative features to be avoided.
Adolescent inpatient clinicians and researchers are likely to need this content to understand the service, compare it with theirs, and find the data clinically useful, thus enhancing relevance of such studies. Hence, the preliminary checklist offers further opportunities to share clinically relevant information with other adolescent inpatient services. Answering some of these key questions offers an opportunity for the reader to clearly understand a service and adopt suitable ideas from these studies. While research serves many purposes, clinical research needs to meet the needs of those at the forefront, adolescents and clinicians themselves.
The features listed in Table 5 were extracted from each study when describing their inpatient unit settings. The features used to define adolescent inpatient units in Table 5  the checklist was one expert who believed the following information was important for the checklist: • Percentage of patients under mental health act.
• Admissions planned/elective and/or acute.
• Details of professional groupings of clinical staff.
The checklist could be used as a flexible prompt for those reporting on adolescent inpatient units. In particular, the checklist can be applied to government policy writers for consideration of reform and quality improvement efforts. The checklists could be useful for journal editors to recommend reporting expectations of submitted manuscripts.

| Limitations and strengths
The eligibility criteria excluded articles not written in English; thus, Psychoeducation. Our philosophy and approach is to provide inpatients with timely information about various aspects of their illness in the hope that they will have better control and grasp of what happens after discharge.

Vidal et al. (2020), United States
The programme included group therapy and daily contact with physicians, a psychologist, occupational therapists, social workers and nurses. Positive Behaviour Reinforcement Systems.

Walker and Kelly (2011) Unknown
The treatment plan assists in maintaining a smooth and coordinated discharge and integration back into the community. Weekly multidisciplinary team meetings take place to discuss progress and future care planning.

West et al. (2017), New Zealand
The unit's sensory room contained a variety of sensory equipment including a rocking chair, weighted blankets, fidget toys, scented oils, candy and teas, pictograph cards (e.g. flashcards depicting pleasant or calming images), music, and projected images (e.g. bubbles floating or rivers running). However, the emerging trend toward a focus on the 12-25 or 15-25 age range means that the degree to which the checklist is useful for these services is limited until more data are available (Colizzi et al., 2020;O'Keeffe et al., 2015).

| Implications
This review informs mental health nursing research by demonstrating the complexity of adolescent inpatient care and its unique features. The checklist can be used to improve reporting and encourage future research into this area (e.g. validation of checklist). For clinical purposes, unit managers and other senior staff can review existing services and plan for new ones using the checklist to consider how the service might function (e.g. discharge procedures) and what might be offered within it (e.g. including facilities such as a gymnasium or kitchen).
The checklist can help policymakers to make informed decisions about service planning and implementation (e.g. admission criteria). Although there are limitations in that the checklist has not been validated, we hope that it will inspire future efforts to critically appraise the ways in which research in adolescent inpatient settings is conducted and reported. This checklist was developed in response to the lack of information provided on research in adolescent inpatient units. Therefore, we hope to see an improvement in the level of information provided in reports on studies conducted in adolescent inpatient units. This will, in turn, assist with quality improvement, through a more detailed description of each setting, in addition to the nomination of areas that require further evaluation. The checklist can promote quality, safety, and greater focus on patient experiences during an admission. This includes increased discussions among clinicians regarding the mission, vision, and values of the organization in an effort to enhance the delivery of their inpatient service.

| CON CLUS ION
The current review has identified that adolescent inpatient units are poorly described, providing insufficient information to inform best practice. Consequently, we have developed a preliminary checklist to improve study design, execution, and generalisability of results.

AUTH O R CO NTR I B UTI O N S
All authors contributed to the design of the research, to the analysis of the results, and to the writing of the manuscript.

ACK N OWLED G EM ENTS
The source of financial grants and other funding should be acknowl-

CO N FLI C T O F I NTE R E S T
We, the authors declare that there is no conflict of interest or ethical issues in the production of this descriptive literature review.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.

E TH I C A L A PPROVA L
This research was partially funded by Ramsay Healthcare. However, the funders were not involved in the decision to publish or preparation of the manuscript.